HomeMy WebLinkAboutApplicationGurfield County ONSITE WASTEWATER
TREATMENT SYSTEM
(owrs)
PERMIT APPLICATION
RECEIVED
Community Development Department
108 Stttstreet, Suite 401
Glenwood Springs, CO 81601
ApR25 2018 (e7ole4s'8212
www.garf¡eld-cou ntv.com
ARFIELD COUNTYG
COMM{JNITY
TYPE OF CONSTRUCÏTON
fl New lnstallation El Alteration E Repair
WASTEWPE
E"Dwelling E Transient Use E Comm./lndustrial tr Non-Domestic
E Other Describe
INVOIVED PARTIES
Phone:
Ca g so
ÞCÊ @
Property Owner:
Mailing Address:
Email Address:
5
Contractor:
Mailing Address:
Email Address:
IPhone¡(Engineer:
Mailing Address:
Email Address:
PROJECT NAME AND LOCATION
BuildingorServiceType:-#Bedrooms: 3 earbageDisposal(Y/Nl /î?
Distance to Nearest Commun¡ty Sewer System:
Was an effort made to connect to the Community Sewer System
c¡rhAssessor's Parcel Number:
Job Address:
_ Lot _ Block _
E Vault E Vault Privy ñ CompostingTolletfísepticTankEl Aeration Plant
E Recycling E P¡t Pr¡vy E lncineration ToiletE Recycling, Potable Use
E other
Typeof OWTS
E Chem¡cal Tollet
Percent Ground SlopeDepth to 1* Ground water tableGround Conditions
E Underground Dlspersal E Above Ground Dispersal& Absorption Íench, Bed or P¡t
El Evapotransp¡rat¡on E Wastewater Pond E Sand F¡lter
E other
El Spring E stream or Creek E cisternts WellWater Source & Type
E Community Water System Name
Effluent
FinalDisposal by
Will Effluent be discharged dlrectly into waters of the State? E Yes .B No
.'l
CERTIFICA TION
Applicant acknowledges that the completeness of the application is conditional Ypgn such further
nìandatory and addifional test and reþorts as may be required by the local health de.partment to be
made and'furnished by the applicant or by the local health department for pu.rposed of the evaluation
of the application; and the isiúance of the permit is_ subject to such terms and conditions as deemed
necessa'ry to ínsuie compliance with rules and regulations made, information and.reports submitted
herewith and required tò be submitted by the applicant are or will be represented to be true and
correct to the belt of my knowledge and belief and are designed to be relied on by the.local
department of health in'evaluating the same for purposes of issuing the. permit a.pplie.d for herein. I
fuither understand that any falsifiıation or misrepresentation may result in the denial of the
application or revocation of any permit granted based upon said application and legal action for perjury
as provided by law.
I hereby acknowledge that I have read and understand the Notice and Certificat¡on above as well as
have provided the required information which is correct and accurate to the best of knowledge.
L3
er Pri Sign Date
G
OFFICIAT USE ONIY L\
Conditions:
Perk Fee:
ór,.5ó.6oôPerm¡t Feeiı75 Fees:æ €
Ba Due:lssue oôaa
Total
ö
Septic Permit:
ıF{}r-5âá¿l
Buílding Permit
t\\ lA
BUILDING/ PLANNING DIVISION
It
DateSigned
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